Missing Americans: Early death in the United States-1933-2021

Abstract

We assessed how many US deaths would have been averted each year, 1933-2021, if US age-specific mortality rates had equaled the average of 21 other wealthy nations. We refer to these excess US deaths as "missing Americans." The United States had lower mortality rates than peer countries in the 1930s-1950s and similar mortality in the 1960s and 1970s. Beginning in the 1980s, however, the United States began experiencing a steady increase in the number of missing Americans, reaching 622,534 in 2019 alone. Excess US deaths surged during the COVID-19 pandemic, reaching 1,009,467 in 2020 and 1,090,103 in 2021. Excess US mortality was particularly pronounced for persons under 65 years. In 2020 and 2021, half of all US deaths under 65 years and 90% of the increase in under-65 mortality from 2019 to 2021 would have been avoided if the United States had the mortality rates of its peers. In 2021, there were 26.4 million years of life lost due to excess US mortality relative to peer nations, and 49% of all missing Americans died before age 65. Black and Native Americans made up a disproportionate share of excess US deaths, although the majority of missing Americans were White.

Keywords: COVID-19; Human Mortality Database; United States; demography; excess deaths; international comparisons; racial disparities.

Fig. 1.

Age-standardized mortality trends in the United States and other wealthy nations. Figure shows deaths per 100,000 person-years: A) 1933–2021 and B) 1980–2021. The solid thick red line is the United States, the dashed thick grey line is the population-weighted average of 21 other wealthy nations, and the thin grey lines are country-specific trends for each of the other nations. Total mortality was age-standardized to the 2000 US population age distribution.

Fig. 2.

Excess deaths and YLL in the United States relative to other wealthy nations, 1933–2021. Source: Human Mortality Database. Note: The figure shows number of deaths in the United States and the counterfactual, the number of deaths that would have occurred in the United States if the United States had ASMRs equal to the average of 21 other wealthy nations. The average of other wealthy nations excludes Portugal prior to 1940, Austria and Japan prior to 1947, New Zealand before 1948, Ireland before 1950, Germany prior to 1956, and Luxembourg prior to 1960. From 1960, all countries are represented. The panels show: A) deaths in the United States and the counterfactual; B) the difference between the two, i.e. the number of excess US deaths or “missing Americans” each year; C) and D) analogous plots for YLL, where each death is weighted by the age-specific life expectancy of other wealthy nations in the year it occurred. Plotting points for all figures are provided in Table S3.

Fig. 3.

Excess US mortality by age group for select years: 1933–2021. Source: Human Mortality Database. Note: The figure shows A) mortality rate ratios, B) excess US deaths, and C) YLL in the United States relative to what would have occurred if the United States had ASMRs equal to the average of 21 other wealthy nations. The group of other wealthy nations excludes Portugal, Austria, Japan, New Zealand, Ireland, and Germany in 1933. From 1960, all countries are represented. Age groups are 0–4, 5–14, 15–24, …, and 85 + years.

Fig. 4.

Excess mortality of US racial/ethnic groups relative to the average of other wealthy nations, 1999–2021. Sources: Multiple Cause Mortality Files from CDC Wonder and Human Mortality Database. The figure shows A) mortality rate ratios comparing US racial/ethnic groups with the average of 21 other wealthy nations and B) numbers of excess US deaths for each group, stratified by age: 0–14, 15–44, 45–64, 65–74, 75–84, and 85 + years. US racial/ethnic groups are Hispanic, non-Hispanic Black (Black), non-Hispanic White (White), non-Hispanic Asian/Pacific Islander (Asian/Pacific Islander), and non-Hispanic American Indian/Alaskan Native (Native American).

Fig. 5.

Age-standardized mortality rates for US racial and ethnic groups and the average of other wealthy nations: 2019, 2020, and 2021. Source: CDC Wonder and Human Mortality Database. Notes: OWN, other wealthy nations. Figure shows age-standardized mortality rates for A) all ages, B) under 65 years, and C) 65 + years. Mortality rates are standardized to the US population age distribution in each year. Mortality rates are shown for the following US populations: Hispanic, non-Hispanic White (White), non-Hispanic Black (Black), non-Hispanic Asian/Pacific Islander (Asian), and non-Hispanic American Indian/Alaskan Native (AIAN). Dashed line shows 2019 (pre-COVID) mortality rates for the average of other wealthy nations.